Systematic review of the effectiveness of remifentanil in term breech pregnancies undergoing external cephalic version

Lomas, S.; Minton, Z.; Daniels, J. P.

Abstract

Background: External cephalic version (ECV) is a moderately painful procedure used to turn a fetus from a non-vertex to cephalic position. This systematic review and meta-analysis compared intravenous remifentanil with other analgesia or no analgesia or placebo on the success rate and associated pain of ECV. Methods: Systematic searches for randomised controlled trials using remifentanil during ECV for non-cephalic term singleton pregnancies were conducted in EMBASE, MEDLINE and Cochrane Library to October 2021. The primary outcomes were successful ECV and maternal pain; secondary outcomes included mode of delivery and adverse effects. The Cochrane Risk of Bias tool was used and meta-analysis undertaken if there were ≥2 comparable studies. Results: Four trials were identified, three placebo-controlled and one vs no analgesia, totalling 482 participants. Comparisons against nitrous oxide or neuraxial anaesthesia were not analysed. Two studies had a low overall risk of bias, and two had some concern for bias. Remifentanil compared with placebo increased the success of ECV by 43% (risk ratio [RR] 1.43; 95% confidence interval [CI] 1.14 to 1.78). Pain scores (0–10) were lower (mean difference −1.97; 95% CI −2.49 to −1.46) whilst there was no impact on caesarean delivery rate (RR 0.97; 95% CI 0.81 to 1.17). Adverse events were rare, with fetal bradycardia observed less often with remifentanil than placebo. Conclusions: Remifentanil increases the procedural success of ECV and reduces pain compared with placebo. Trials were at low risk of bias and contained a sufficient number of participants to have reasonable confidence in this finding.

Citation

Lomas, S., Minton, Z., & Daniels, J. P. (2023). Systematic review of the effectiveness of remifentanil in term breech pregnancies undergoing external cephalic version. International Journal of Obstetric Anesthesia, 54, Article 103649. https://doi.org/10.1016/j.ijoa.2023.103649

• Journal Article Type: Article
• Acceptance Date: Mar 1, 2023
• Online Publication Date: Mar 7, 2023
• Publication Date: 2023-05
• Deposit Date: Mar 28, 2023
• Publicly Available Date: Apr 4, 2023
• Journal: International Journal of Obstetric Anesthesia
• Print ISSN: 0959-289X
• Electronic ISSN: 1532-3374
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 54
• Article Number: 103649
• DOI: https://doi.org/10.1016/j.ijoa.2023.103649
• Keywords: Analgesia; Breech presentation; Extracephalic version; Meta-analysis; Remifentanil
• Public URL: https://nottingham-repository.worktribe.com/output/18998398
• Publisher URL: https://www.obstetanesthesia.com/article/S0959-289X(23)00025-0/fulltext